Cleeve Dental Surgery

Updated 27 April 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008

The inspection took place on 16 March 2016 and was led by a CQC inspector who was supported by an Inspection Manager, and a specialist dental advisor. We informed the local NHS England area team and Healthwatch that we were inspecting the practice; however we did not receive any information of concern from them.

During the inspection we spoke with the dentist, the practice manager (who is also the dental nurse), the trainee dental nurse and the receptionist. We received feedback from patient surveys completed by 31 patients, as well as comment cards, completed by 15 patients, about the quality of the service. We reviewed policies, procedures and other documents relating to the management of the service. To assess the quality of care provided we looked at practice policies and protocols, and other records relating to the management of the service.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 27 April 2016

We carried out an announced comprehensive inspection on 16 March 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Cleeve Dental Surgery is centrally located in Cleeve, Bristol, and is easily accessible for patients who live in North Somerset and surrounding areas. It has two dental treatment rooms, one on the first floor that is used occasionally by the hygienist, the other on the ground floor that is used by the dentist.

There is free parking on-site or on the nearby roads, but no disabled parking bays on site. The practice provides mostly NHS dental treatment to adults and children. It also provides a number of additional private treatments such as cosmetic crowns, and dental implants.

The practice employs one dentist, who is the principal dentist. There is one hygienist. They are supported by one dental nurse, who is also the practice manager, one trainee dental nurse and one full-time receptionist. The practice is open from Monday to Thursday between 9:00 am and 5.30 pm; and on Friday between 9:00 am and 1:00 pm. Emergency appointments are available from 12:00 pm to 2:30 pm each day via 111, and for the surgery’s own patients.

The practice’s premises were purchased in 2003 and consist of two large treatment rooms on the ground floor, a patient waiting area, a decontamination room, and a staff room.

The principal dentist is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Although we did not speak to any patients during our inspection, we invited the practice to offer any patients who wished to do so, the opportunity to speak to us on the telephone about their experience. We received 15 comment cards that had been completed by patients prior to our inspection, all of which contained extremely positive comments about the practice. Patients told us that they were very happy with the quality of the dental care they received; that staff were professional and caring, and that the practice’s hygienist had helped them manage and reduce their gum disease.

Our key findings were:

• We received consistently good feedback from patients about the quality of the practice’s staff and the effectiveness of their treatment.

• Patients’ care and treatment was planned and delivered in line with evidence-based guidelines, best practice and current legislation. Patients’ dental care records provided an accurate, thorough and contemporaneous record of patient care.
• There was an effective system in place for reporting and recording significant events, and learning from them was shared widely with staff.
• Safeguarding patients was given high priority within the practice, and staff responded quickly and professionally to concerns raised.
• Infection control and decontamination procedures were robust, ensuring patients’ safety.
• Staff had an understating of the Mental Capacity Act (2005) and the importance of gaining patients’ informed consent.
• Patients received their care and treatment from well-trained and supported staff, who received regular appraisal and observation of their performance. Staff enjoyed their work citing good team work, support and training as the main reasons.
• The practice was well-led, with good governance and management procedures in place.

There were areas where the provider could make improvements and should:

• Review and update the information recorded on the NHS Choices website to ensure there is clear information about Cleeve Dental Surgery’s out-of-hours provision for patients.
• Review staff training to ensure that all staff attend Mental Capacity Act Training, to better support their own professional practice, and to ensure the rights of patients are respected and responded to appropriately.
• Review the storage of all rubber dam kits and dental hand pieces to ensure that the storage of these instruments reflects the changes in the 2013 edition of HTM 01 05.